Provider Demographics
NPI:1285694000
Name:SPARKS, JENNIFER DAWN (OD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:DAWN
Last Name:SPARKS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2640 BIEHN ST
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-1181
Mailing Address - Country:US
Mailing Address - Phone:541-884-8322
Mailing Address - Fax:541-884-7121
Practice Address - Street 1:629 MAIN ST
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-6007
Practice Address - Country:US
Practice Address - Phone:541-884-8322
Practice Address - Fax:541-884-7121
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2975T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP00208178OtherRAILROAD MEDICARE
OR022812Medicaid
ORXSD000850OtherMEDI-CAL
OR004571011OtherBCBS
ORXSD000860OtherMEDI-CAL
ORP00208178OtherRAILROAD MEDICARE
ORR120503Medicare PIN
OR0447820001Medicare NSC
OR004571011OtherBCBS
ORXSD000850OtherMEDI-CAL